Speculums Are Not One-Size-Fits-All


By Lauren Streicher, MD



Are you one of those “hard-to-fit” types when it comes to jeans? Rest assured that thinking your thighs look fat and sending numerous sales people back to the racks is painless compared to being a “hard-to-fit” type when it comes to speculums.

The problem is, much like those skinny jeans, speculums are not one-size-fits-all. The speculum I use for a 16-year-old virgin is a completely different instrument than I would use for a 40-year-old with 3 kids, the 70-year-old who is well into menopause, the 4”10’ woman, or the 6" woman. My choice of speculum is not only dependent on the size of the vaginal opening, but also on variables such as the length of the vagina, the elasticity of the vaginal walls, the position of the uterus, and what I need to accomplish while up there. For example, the amount of exposure I need to swab vaginal discharge is different than what I need to do a Pap test, a uterine sampling or a major procedure.

The modern speculum was invented (yes, by a man) in 1845. You would think that by now someone would have come up with something better than 2 metal duck bills to allow visualization of the cervix, but other than the brief appearance of a one-size-fits-all soft inflatable speculum a few years ago, there haven’t really any better options for vaginal viewing.

So while that metal speculum is not going to go away, and never going to feel good, it shouldn’t be excruciating. If your pap test goes beyond “a little pressure,” and it pinches, bites or hurts, don’t be shy. Say something! Sometimes a minor readjustment or changing instruments can make a world of difference. But unless you tell your gyne, he or she won’t know that the speculum is digging or pulling on something it shouldn’t. Not to mention if the speculum part of the exam hurts, the rest of the exam is likely to be painful as well since your pelvic muscles will involuntary contract into ‘keep out mode” to protect themselves from further agony.

I know it’s never intentional, but clamping your knees together and lifting your bottom off the table, makes it really difficult for the doctor to get a speculum in and see what needs to be seen. It will also make the exam take longer, and yes, hurt more. It helps to take your mind off the fact that a large metal object is about to enter your vagina by deep breathing or talking to your gynecologist about something unrelated. I had one woman who instead of talking to me, talked to her sister on her cell phone during her Pap smear to take her mind off what I was doing! I also have a patient who precedes her annual exam with a 2-martini lunch.


If you are not an easy fit, I would skip the martinis, but you’re probably better off seeing a gynecologist as opposed to a general doctor for your annual Pap. Gynecologists are not only the most experienced at inserting speculums, but have multiple sizes that vary in length, width and how far they open. If only the jean store could be so accommodating.

Originally published  10/14 /10 doctoroz.com 

Why the New ‘No Pelvic Exam’ Recommendation Is Flawed



By Lauren Streicher, MD

Published Jun 28, 2014,  EveryDay Health

The American College of Physicians (the group that represents INTERNISTS, not GYNECOLOGISTS) published a recommendation this week stating that non-pregnant women who do not have specific complaints need not have a gynecologic exam.

Before you scream ‘WOO-HOO” and start the celebration, I need to point out a few flaws in their thinking.

No Pelvic Complaint Does Not Equal No Pelvic Problem

Let’s start with the “no complaint” part

Studies have shown that the majority of women who have conditions such as urinary incontinence, fecal incontinence, vaginal odor, vaginal dryness, unusual discharge, and vulvar discomfort do not mention it to their doctor, either out of embarrassment or because they think involuntary loss of urine and painful sex are “normal” parts of aging. Studies also show that the majority of doctors do not ask if these symptoms exist, and more often than not, these conditions go untreated. So much for no complaints.

Many conditions don’t have symptoms

Most women with growing fibroids, pelvic infections that can lead to infertility, ovarian cysts or a myriad of other pelvic conditions do not have symptoms, but early diagnose can make a big difference when it comes to avoiding problems down the road. Just a few months ago I saw a 55-year-old woman who had not seen a gynecologist for years. Her internist told her that after a hysterectomy a pelvic exam was unnecessary. Since she had “no complaints” her doctor did not put a speculum in or look in her vagina at her annual exam.

Eventually, she did have a complaint: a bloody vaginal discharge. She came to me and a 15-second speculum exam detected what turned out to be a Stage 4 vaginal cancer. These things don’t turn up overnight, and a vaginal exam long before it became symptomatic would have detected her problem when it was early and treatable.

How to Avoid Potential Harms of Pelvic Exams

The obvious question is, “What’s the harm in performing an annual speculum and bimanual pelvic exam?” Here are three, according to The American College of Physicians:

Pelvic exams are embarrassing

For whom? If the doctor is embarrassed, the patient will be embarrassed. Not to mention, rectal exams are embarrassing. Testicular exams are embarrassing. Should those be omitted as well? This propagates and validates that many women’s health concerns are taboo topics. Shh! Don’t talk about your vaginal odor. Don’t talk about your sexual concerns. Don’t talk about your incontinence. Not even to your doctor. If every other body part is examined but the genitals, it sends a clear message that the pelvis, vagina and vulva are not part of the regular comprehensive physical. The pelvic exam should be normalized, not marginalized.

Pelvic exams are painful

The article reports that up to 60 percent of women said pelvic exams were painful. 60 percent! One has to wonder why the majority of the patients in the study experienced pain. Was the person inserting the speculum inexperienced? Did he or she use a jumbo speculum? (One size does not fit all!) Maybe some exams were painful because the woman had terrible vaginal dryness that she forgot to “complain about.” A pelvic exam should never be painful, and if it is, it may indicate a problem.

A pelvic exam takes time

Yes it does. At least one minute. So does listening to a heart, or doing a breast exam. I am guessing my patient with vaginal cancer would have been glad to put up with one minute of embarrassment instead of undergoing cancer treatments and fighting for her life.

Gynecologists Still Recommend a Yearly Pelvic Exam

The American Congress of Obstetricians and Gynecologists (ACOG) continues to recommend an annual pelvic exam, even in a non-pap test year. To be fair, many internists are totally comfortable doing a pelvic exam and are eager to address many of the issues I described above. Just last week I gave a lecture to a group of internists who wanted to learn more about evaluating and treating vulvar and vaginal conditions. The real message is, there is value in an annual exam, but it depends on who does it. So take your pelvis to a doctor (or advanced practice nurse) who is interested, competent, and not embarrassed.

Full-Figured? Make Your Gynecologic Exam Less Embarrassing

By Lauren Streicher, MD

Published Oct 28, 2014

Are you one of those full-figured women who skips your annual gynecological exam since suffering from some awful gynecologic problem seems infinitely more appealing than being forced to get on a scale, put on a skimpy paper gown and get lectured about your weight?

You’re not alone. The fact is, women who are significantly overweight tend to avoid the doctor until they are so sick they have no choice.

Here are my tips to make a visit to the gynecologist a lot less stressful if you are on the large side.

Problem: “Every time the medical assistant hands me that flimsy gown and smirks as she leaves the room knowing full well that there’s no way it will fit, I want to die. I dread attempting to wrap myself in one of those paper things that barely cover my breasts and leave a gap across my belly. By the time the doctor walks in, I am usually clutching multiple scraps of tattered soggy paper in a futile attempt to cover various body parts. It’s humiliating.”

Solution: It would be nice if every office provided roomy cloth gowns. But there’s no rule that says you can’t provide your own exam gown. Call prior to your appointment and inquire if your doctor prefers gowns that open in the front or the back.

Keep in mind that your gown may get stained, especially if you are having a procedure. Bring something that you won’t care if it is ruined. A wrap-around robe or loose dress with a front zipper is fine. GetJanes.com not only sells wellness examination gowns, but also donates part of their proceeds to enable women to get mammograms.

Problem: “It’s all about being naked. I know that at some point I am going to have to bare my body in a brightly lit room. There’s no hiding my stomach, butt, thighs, and I just find the whole experience so embarrassing that I would rather die from some dread disease than expose myself.”

Solution: It would be nice if we could do our exam in the dark! I had one overweight woman drop a cloth over her face during the exam and mumble, “If I can’t see you, you’re not here, and this isn’t really happening.” Mention, “I’m on the modest side and I would appreciate if you kept me covered as much as possible.” Massage therapists use an extra cloth to cover the nonessential parts and there is no reason that your doctor can’t also.

If your doctor seems oblivious to your need for coverage, it’s probably because we are. You may be mortified, but we spend our entire day around naked bodies and it’s the rare patient that looks like she is ready for the centerfold of Playboy.

Problem: “I know I should go to the doctor but I keep putting it off. I’m sure I’m going to get yelled at about my weight. Last time I went to the gynecologist I really wanted to discuss the fact that my sex life was essentially gone. All my gyne seemed to want to talk about was my weight. By the time he told me that I was at risk for dropping dead from a heart attack unless diabetes got me first, it just didn’t seem appropriate to bring up my lack of libido.”

Solution: One patient said to me, after her fifth year at the same weight, “I just know you are going to yell at me because I haven’t lost the weight.” When I reminded her that I had never yelled at her but had simply acknowledged that her weight had not changed and suggested we talk about strategies to deal with it, she admitted that her annual visit was really a time that she was forced to acknowledge that an entire year had gone by without losing any weight, and that she was actually yelling at herself.

It is frustrating to have a doctor so focused on your weight that none of your other concerns are addressed. Your best bet to avoid a discussion about your weight is to start by saying, “I know I need to lose weight, but since we have a limited amount of time I would prefer to discuss other health concerns today. Then whip out your list and go for it…my libido is gone, my bladder is leaking….” or whatever. That way, the things that are important to you will be addressed as priorities.

Problem: “I haven’t been to my doctor in five years because I know they will force me to get on the scale and I just don’t want to know.”

Solution: It’s not the army. No one is going to force you to do anything. It’s much better to get everything you need done other than your weight rather than to not come at all. If someone declines to be weighed, I will generally ask for a ballpark figure. You also have the option of getting weighed “backwards.” We will know, but you won’t. Exceptions to taking a pass on your weight? Pregnancy, certain medications, and surgery require an accurate weight.